Improving the Management of Prolonged Seizures in Wessex

Please complete the form below for patients who present to your hospital.

Please enter your data below and click submit. Please do not include any patient identifiable data (such as names or addresses).

​Demographics

* Indicates required field

Select Your Hospital *

Location *

Emergency DepartmentAssessment UnitWard

Age *

Sex *

MaleFemale

Was the Child Febrile? *

YesNo

Admission

Date and Time seizure started *

Time 111/999 responder attended *

Time of admission (+/- time for transfer) *

Speciality and grade of staff present *

Seizure Management

1st Anticonvulsant *

Route *

Dose *

Time *

Location *

If pre-hospital, then given by parents or crew?

2nd Anticonvulsant *

Route *

Dose *

Time *

Location *

3rd Anticonvulsant *

Route *

Dose *

Time *

Location *

4th Anticonvulsant *

Route *

Dose *

Time *

Location *

Any other drugs given eg. antibiotics? Time and Dose? *

Access obtained IV/IO? Time? *

Time of seizure termination *

Total duration of seizure (minutes) *

If there is any other information relating to this case that you feel would be helpful to include, please write it here (i.e. Was this a prolonged febrile convulsion? Does the child have a background of seizures? Do they have a personalised seizure management plan?) *

Escalation

Paediatric Consultant in attendance? *

YesNo

Time Paediatric Consultant called? *

Time Paediatric Consultant attended? *

Local ICU in attendance? *

YesNo

Time local ICU called? *

Time local ICU attended? *

PICU contacted? *

YesNo

Time PICU called? *

Time PICU in attendance? *

Blood Gasses

Date/Time *

A/V/C *

pH *

pCO2 *

pO2 *

BE *

Lactate *

Na *

K *

Glucose *

Date/Time *

A/V/C *

pH *

pCO2 *

pO2 *

BE *

Lactate *

Na *

K *

Glucose *

Date/Time *

A/V/C *

pH *

pCO2 *

pO2 *

BE *

Lactate *

Na *

K *

Glucose *

Date/Time *

A/V/C *

pH *

pCO2 *

pO2 *

BE *

Lactate *

Na *

K *

Glucose *

Intubation & Ventilation

Was a jaw thrust or chin lift required at any time? *

YesNo

Was an airway adjunct used at any time? *

YesNo

Did the child require bag/mask ventilation at any time? *

YesNo

Was the child intubated at any stage of treatment? *

YesNo

If yes, what was the indication? (tick all that apply) *

Thiopentone was used to terminate the seizureFailure to wake up in the post-ictal periodHypoventilation or apnoeaTo facilitate scanning

Date/Time of intubation *

Grade/Speciality *

Transfer to alternative place of care? *

WardHDUICUPICU

Time departed? *

Location, date and time of extubation *

Please scan and upload the paramedic sheet if possible. *

Max file size: 20MB

Email *

Please leave you email address so we may contact you with any questions about the data submitted.